Tuesday, March 15, 2016

Elite Airways Visit North Platte For Essential Air Bid



Lee Bird Field is trying to keep up with the Essential Air Service. They need to have two round trip flights a day in order to keep up with the standards. That's why they're looking into hiring airlines like Elite Airways.

The jet engine of the Bombardier CRJ-200 aircraft roared as it prepared for takeoff from Lee Bird Field in North Platte.

"It's very nice inside." Airport Manager Mike Sharkey said. "It really is nice."

The 50-seat charter plane cruises at 488 miles per hour, making trips from North Platte to Denver as fast as a one hour flight from takeoff to touchdown.

"About the hour block time or so makes a lot of economic sense." Elite Airways President John Pearsall said.

The jet is one of three planes which could find its home in North Platte, Kearney and Denver if elite airways beats out six other airline services in a bid for a contract with Lee Bird Field.

"You don't get this kind of room in another plane for the same price you would get at another airline." Flight Attendant Madalyn Then said.

Elite Airways is one of two of the bidding airlines offering jet planes. The CRJ-200 would be able to make the trip from North Platte to Denver for only $60 per ticket. The airline is even looking at making trips to other cities outside of Denver.

"We actually spoke to the folks her today and told them we were considering going east toward Minneapolis or Chicago." Pearsall said.

Expanding East is one of the main draws Elite saw in making a home in North Platte.

"Knowing that if we were to grow the market in each of these cities, that we could go further East with it, that was the key." Pearsall said.

Regardless of the airline being Elite or one of the other six, the benefits don't just apply to the air service.

"I think we're going to develop the traffic." Pearsall said. "That's the key. I think because the fact that jet is being out there there's more people that are going to ride them as opposed to driving or taking another form of transportation."

Airport officials will know which airline they'll be taking in around mid to late April. Those flights will start taking off from Lee Bird Field at the beginning of November.

Original article can be found here:   http://www.knopnews2.com

Flabob Airport (KRIR) hangar fire deemed accident



A fire that destroyed a 3,000-square-foot airplane hangar and an airplane Tuesday, March, 15, at Flabob Airport in Jurupa Valley was determined to be an accident.

Cal Fire/Riverside County Fire Department investigators are still trying to determine exactly what caused the fire, spokeswoman Jody Hagemann said Thursday. They have ruled out that it was intentional.

Capt. Lucas Spelman said Tuesday that the steel-sided building with a corrugated metal roof was a complete loss, as well as the airplane that was inside. Investigators estimated the damage to be $130,000.

The plane was used by volunteers with the Experimental Aircraft Association's Young Eagles program to teach children how to fly. Experimental Aircraft Association chapter president Jim O'Brien said that despite the loss of the plane, the program will continue every second Saturday of the month.

One person suffered minor burns in the fire. An ambulance crew took the person to the hospital before firefighters arrived.

Flames from the burning building damaged half of a hangar on one side of the main fire and a quarter of the hanger on the other side, Spelman estimated.

No planes were inside the partially damaged hangars, Spelman said. Those buildings contained motorcycles, tools and other items.

Original article can be found here:  http://www.pe.com

Cessna U206G Stationair, N734VB: Fatal accident occurred July 19, 2015 in Trapper Creek, Alaska

National Transportation Safety Board issues final report on father's fatal plane crash at daughter's wedding





The National Transportation Safety Board said a Trapper Creek plane crash last summer that killed a father flying over his daughter’s wedding reception happened when the pilot flew into trees during a low pass.

In a Tuesday update on the July 19 crash that killed 54-year-old Michael Zagula, the board said its probable cause was “the pilot's failure to maintain clearance from trees while intentionally maneuvering close to the ground.” Witnesses had seen Zagula’s Cessna U206G making “treetop-level” passes over the forested area where the reception took place, at speeds of 100 to 120 knots -- about 115 to 140 mph.

“The airplane made two successful passes over the group, and, on the third pass, the airplane entered a right turn and initiated a climb just before impacting the top of a spruce tree,” investigators wrote. “The climb continued briefly before the airplane rolled inverted and descended through the trees to ground impact.”

Mat-Su Borough first responders traveled to the crash site near Petersville Road on four-wheelers, following initial reports at about 7 p.m. on July 19. Zagula’s body was subsequently taken to the State Medical Examiner Office.

The final report on the accident's probable cause also noted that drugs were present in the pilot's system but stopped short of declaring them a factor.

The report said an NTSB toxicology examination performed on Zagula, the Cessna’s pilot and sole occupant, had identified “likely impairing levels of tetrahydrocannabinol (THC) and low levels of diazepam” in his blood. THC is the active component of marijuana, while diazepam is an anti-anxiety drug originally sold as Valium.

When investigators examined the Cessna's airframe and engine, the report said, they found "no mechanical malfunctions or anomalies that would have precluded normal operation."

NTSB investigator Brice Banning, who conducted the Trapper Creek investigation, said Tuesday that the drug findings from the toxicology examination weren’t listed in the crash’s probable cause because they couldn’t be positively linked to it.

“After death, there’s a redistribution of drugs in the body that makes analysis very difficult, and we were unable to determine if it played a role,” Banning said. “It was something we were concerned at and we looked at very thoroughly -- but we were just unable to determine if it was a factor.”

Alaskans legalized the recreational use of marijuana in a 2014 vote.

The NTSB investigation of the crash that killed Zagula is one of several last year depicted by the Smithsonian Channel show “Alaska Aircrash Investigations.” Investigators with the board have said that further information on crashes depicted in the show will be released ahead of the relevant episodes’ air dates.

The “Alaska Aircrash Investigations” episode covering the Trapper Creek crash is set to air Sunday at 8 p.m. Alaska time.

Original article can be found here: http://www.adn.com

http://dms.ntsb.gov



MICHAEL J. ZAGULA: http://registry.faa.gov/N734VB 

NTSB Identification: ANC15FA050
14 CFR Part 91: General Aviation
Accident occurred Sunday, July 19, 2015 in Trapper Creek, AK
Probable Cause Approval Date: 03/14/2016
Aircraft: CESSNA U206G, registration: N734VB
Injuries: 1 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The pilot was performing a series of low passes over a group of people at an outdoor wedding reception party. Witnesses observed the airplane fly over the party at near tree-top level traveling between 100 and120 knots. The airplane made two successful passes over the group, and, on the third pass, the airplane entered a right turn and initiated a climb just before impacting the top of a spruce tree. The climb continued briefly before the airplane rolled inverted and descended through the trees to ground impact. 

Postaccident examination of the airframe and engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. Toxicology testing identified likely impairing levels of tetrahydrocannabinol (THC) and low levels of diazepam in the pilot's blood. However, diazepam and THC levels are known to change after death and may be elevated due to movement of the drugs out of storage sites into blood. Therefore, it was not possible to determine if the pilot was impaired from the effects of THC and/or diazepam at the time of the accident.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain clearance from trees while intentionally maneuvering close to the ground.

HISTORY OF FLIGHT

On July 19, 2015, about 1915 Alaska daylight time, a Cessna U206G airplane, N734VB, was destroyed after it impacted tree and tundra-covered terrain, following a loss of control while maneuvering at low altitude near Trapper Creek, Alaska. The airplane was being operated by the pilot as a visual flight rules (VFR) local flight under the provisions of Title 14, Code of Federal Regulations (CFR) Part 91, when the accident occurred. The solo commercial pilot was fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight departed a private airstrip near Curry Ridge, Alaska.

The pilot was performing a series of low passes over an outdoor wedding reception party when the accident occurred.

During an on-scene interview with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on July 20, a witness reported that while attending the outdoor wedding reception party, he observed the accident airplane fly over the wedding reception party at near tree-top level, traveling between 100-120 knots. He said that the airplane made two successful passes over the group of guests, and on the third pass, the airplane entered a right turn prior to impacting the top of a spruce tree with the main landing gear. The witness noted that after the airplane struck the treetop, he was unable see the airplane descend into the tree and tundra-covered terrain.

During a telephone conversation with the NTSB IIC on July 22, a second witness reported that he observed the airplane descend over the wedding reception party at near treetop level. He stated that the airplane initiated a climb just before impacting the top of a spruce tree, and the climb continued for about 5 to 6 seconds, before the airplane rolled inverted and subsequently disappeared into the trees.

PERSONNEL INFORMATION 

The pilot, age 54, held a commercial pilot certificate with an airplane mutli-engine land, single-engine land rating and instrument airplane. Additionally, he held a flight engineer certificate for a turbo-propeller powered airplane. His most recent third-class medical was issued on January 3, 2013 with no limitations.

No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from a review of the airmen Federal Aviation Administration (FAA) records on file in the Airman and Medical Records Center located in Oklahoma City. On the pilot's application for medical certificate, dated January 3, 2013 he indicated that his total aeronautical experience was about 2,100 hours, of which 400 were in the previous 6 months.

AIRCRAFT INFORMATION

The six-seat, high-wing, tricycle gear airplane, Cessna U206G, serial number U206048785, was manufactured in 1979. It was powered by a Continental Motors IO-520 series.

No airframe or engine logbooks were discovered for examination. Total time for the engine and airframe are unknown. 

METEOROLOGICAL INFORMATION 

The closest weather reporting facility is Talkeetna Airport, Talkeetna, AK approximately 6 miles east of the accident site. At 1853, an aviation routine weather report (METAR) at Talkeetna, Alaska, reported in part: wind 310 degrees at 3 knots, visibility, 10 statute miles, clear skies; 71 degrees F; dew point 41 degrees F; altimeter, 30.13 inHG.



WRECKAGE AND IMPACT INFORMATION

The NTSB IIC, along with a Federal Aviation Administration (FAA) safety inspector from Denali Certificate Management Office (CMO), reached the accident site on the morning of July 20. 

All of the airplane's major components were found at the main wreckage site. The wreckage was located in an area of densely populated birch and spruce trees, on its right side at an elevation of about 436 feet mean sea level (MSL). Portions of the fragmented airplane were scattered along a debris path oriented along a magnetic heading of 260 degrees, which measured about 110 feet in length. (All headings/ bearings noted in this report are magnetic).

An area believed to be the initial impact site was marked by a broken treetop, atop an estimated 40-foot tall birch tree. The initial ground scar was discernable by disturbed vegetation. Small wreckage fragments were found near the initial ground scar. The distance between the initial impact point and the initial ground scar was about 65 feet.

The cockpit area separated forward of the main landing gear box and was extensively damaged. The throttle was found in the idle position. The mixture and propeller control were found in the full-forward position. 

The airplane's right wing separated from its forward attach point; remained attached at its rear attach point, but separated about 6 inches inboard of the fuselage structure. A large elliptical impact area was present about ¾ span outboard of the wing with extensive accordion style, leading edge crushing from the elliptical impact area outboard to the tip. The outboard portion of the right wing separated near the elliptical impact area. The wing's flight control surfaces remained attached to their respective attach points but sustained impact damage. 

The airplane's left wing separated from its attach points, and fragmented into three major sections. An elliptical impact area was present approximately ¾ span outboard of the wing with extensive accordion style, leading edge crushing from the elliptical impact area outboard to the tip. The wing's flight control surfaces remained attached to their respective attach points, and were relatively undamaged. 

The aft fuselage and empennage exhibited extensive accordion style crushing. The vertical stabilizer and rudder remained attached to the empennage, and were relatively free of impact damage. 

The left horizontal stabilizer remained attached to the empennage, but exhibited spanwise downward bending about ¾ span outboard to the tip. The left elevator remained attached to its inboard attach point but separated at its outboard attach point, and was fracture about mid-span. 

The right horizontal stabilizer sustained impact damage, but remained attached to the empennage. The right elevator remained attached to its respective attach points, and was relatively free of impact damage.

The engine separated from its engine mounts, came to rest inverted and sustained impact damage to the front and underside. The exhaust tube had malleable bending and folding, producing sharp creases that were not cracked or broken along the creases. 

The propeller and hub remained attached to the engine crankshaft. All three of the propeller blades remained attached to the propeller hub assembly and exhibited aft bending. One of the three propeller blades exhibited slight torsional "S" twisting, and the propeller tip separated from the blade. 

All the primary flight controls were identified at the accident site. Elevator control continuity was established from the control column to the aft elevator bellcrank. Rudder control continuity was established from the rudder torque tube to the rudder bellcrank. Aileron control continuity could not be established at the accident site due to numerous fractures in the system, but all fractures exhibited features consistent with tension overload. 

The wreckage was examined at a private residence, Trapper Creek, AK, on July 22, 2015. In attendance for the examination was the NTSB IIC, along with an air safety investigator from Textron Aviation.

After the wreckage was recovered, aileron control continuity was established in the direct cables, from the control column to the point where the cables fractured with features consistent with tension overload, to the left and right aileron bellcranks. The balance cable remained attached to the right aileron bellcrank, but separated from the left aileron bellcrank and fractured with features consistent with tension overload. The length of the balance cable was consistent with the required length to reach the left aileron bellcrank. 

The examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

MEDICAL AND PATHOLOGICAL INFORMATION

A post mortem examination was conducted under the authority of the Alaska State Medical Examiner, Anchorage, Alaska, on July 20, 2015. The pilot's cause of death was determined to be multiple blunt force injuries. Additionally, the autopsy identified severe coronary artery disease in all vessels with maximal narrowing of 75 to 85% in the distal right coronary artery; there was no gross evidence of any scarring of the heart muscle. However, the investigation was unable to determine if pilot impairment or incapacitation resulting from the symptoms from coronary artery disease contributed to the probable cause of the accident. 

The FAA Bioaeronautical Laboratory identified diazepam (0.057 ug/ml) and its active metabolite nordiazepam (0.04 ug/ml) in the pilot's blood. Nordiazepam and other active diazepam metabolites, oxazepam and temazepam, were detected in urine. Additionally, tetrahydrocannabinol was detected in blood (0.0028 ug/ml) and its inactive metabolite tetrahydrocannabinol carboxylic acid was detected in blood (0.0096 ug/ml) and urine (0.1487 ug/ml). 

Diazepam (marketed under the trade name Valium) is a prescription medication used to relieve anxiety, muscle spasms, seizures, and to control agitation caused by alcohol withdrawal. Diazepam may cause reduced concentration, impaired speech patterns and content, and amnesia; some of its effects may last for days. The drug carries a warning about engaging in hazardous occupations requiring complete mental alertness such as driving a motor vehicle when using diazepam. Therapeutic blood concentrations typically range from 0.1-1.0 ug/ml.

Tetrahydrocannabinol (THC) is the psychoactive compound found in marijuana with therapeutic levels as low as 0.001 ug/ml. THC has mood altering effects including euphoria, relaxed inhibitions, sense of well-being, disorientation, image distortion, and psychosis. The ability to concentrate and maintain attention is decreased during marijuana use, and impairment of hand-eye coordination is dose-related over a wide range of dosages. Impairment in retention time and tracking, subjective sleepiness, distortion of time and distance, vigilance, and loss of coordination in divided attention tasks have all been reported. Users may be able to "pull themselves together" to concentrate on simple tasks for brief periods of time. Significant performance impairments are usually observed for at least one to two hours following marijuana use, and residual effects have been reported up to 24 hours.

Diazepam and THC levels are prone to change after death and may be elevated due to movement of the drug out of storage sites into blood. Therefore, although toxicology testing identified likely impairing levels of THC (0.0028 ug/ml) and low levels of diazepam in the pilot's cavity blood after the accident, the investigation was unable to determine if the pilot was impaired from the effects THC or the combined effects of THC and diazepam at or around the time of the accident.

A copy of the NTSB's Medical Officer's Factual Report is available in the public docket for this accident.

TESTS AND RESEARCH

Engine 

On July 22, 2015, an engine examination was performed by the NTSB IIC. No anomalies, contamination, or evidence of malfunction was found in any of the engine accessories. The cylinders, pistons, valve train, crankshaft, and other internal components were all without evidence of anomaly or malfunction. 

Both magnetos were removed from the engine and the coupling was rotated by hand. When the coupling was rotated, blue spark was observed on the top ignition leads.

ADDITIONAL INFORMATION

Federal Aviation Regulations

The accident flight was operated under the provisions of Part 91 as a personal flight, and was subject to the part's applicable rules. Section 91.119, states, in part: No person may operate an aircraft below the following altitudes: over any congested area of a city, town, or settlement, or over any open air assembly of persons, at an altitude of 1,000 feet above the highest obstacle within a horizontal radius of 2,000 feet of the aircraft.

FAA Flight Standards District Office: FAA Anchorage FSDO-03

Incidents occurred March 12, 2016 near Charlotte Douglas International Airport (KCLT), Charlotte, Mecklenburg County, North Carolina



CHARLOTTE, N.C. -- Charlotte-Mecklenburg Police and the FAA are looking for the owner of a drone who flew dangerously close to two airliners.

Both incidents happened Saturday night between 6:15 and 6:45 and was captured on tower communications.

Pilot: "I just passed some little hovercraft thing."

Tower: You think it might be a drone?

Pilot: "Yes sir."

The tower sent Snoopy, CMPD'S police helicopter to look for the person flying the drone; it was traced to an area near the 3400 block of Brookshire Boulevard.

The second pilot also talked to the tower.

Pilot: "It was at 2300 feet, just as we passed over the top of him."

Close calls like this worry passengers like Laura Bailey, who flew in from Boston.

"I think they should work on putting the genie back in the bottle-- especially on this one," she said.

Ben Smith disagrees; he's been a helicopter pilot for 30 years.

"The fact there is a drone up there it's just one more thing in the sky. I'm not in the least way concerned about that," he said.

If police catch up with the drone owner, he could face stiff federal penalties including jail and fines totaling hundreds of thousands of dollars. 

Story and video:  http://www.wcnc.com

Tulare County Sheriff's Office determined to get back into the air a month after deadly plane crash: Flight Design CTLS, N911TS, fatal accident occurred February 10, 2016 near Visalia Municipal Airport (KVIS), Tulare County, California

Tulare County sheriff's Deputy Scott Ballantyne and Pilot James Chavez


VISALIA, Calif. (KFSN) -- More than a month after a Tulare County Sheriff's Office plane crashed, killing a pilot and deputy on board, the department is determined to get back in the air as soon as possible. The sheriff has said that's what pilot James Chavez and Deputy Scott Ballantyne would have wanted.

Aviation Unit head Dave Williams agrees, and believes it will be good for department morale. Williams has been with the Tulare County Sheriff's Office for decades, holding a variety of positions. But his post-retirement role as head of the department's aviation unit has been most enjoyable. "I gotta say that being able to be up in the air and provide that type of assist, is probably one of the best jobs in law enforcement," Williams said.

There's inherent risk in flying, and the entire law enforcement community was reminded of it when Sheriff One crashed into a hillside after responding to a call near Springville. Deputy Scott Ballantyne and pilot James Chavez died, and have since been remembered as good men who kept the Tulare County community safe. "They both loved what they were doing, they absolutely thought that being in the aviation unit was the greatest assignment they could ever have," Williams said.

Sheriff One responded to any and all public safety calls, including deadly accident scenes, dangerous drag races and even fires in the hills. Chavez and Ballantyne communicated with and protected deputies on the ground. They busted large scale marijuana grows and helped take down gang members. It's all why Williams and the Sheriff believe it's so important to get the aviation program up and running again-even as they await results on the cause of the crash. "If there's any area where we can improve safety, we will do it," Williams said.

Williams says they're working on a claim with the insurance company to replace Sheriff One. But another plane, identical to the one used in Kings County, should arrive within a month. A camera system will need to be installed, and another crew will need to be trained.

The sheriff's office was recently given the go-ahead to purchase their first drone. That will also be part of the aviation unit, and should also be up and running within a couple of months.

Story and video:  http://abc30.com

COUNTY OF TULARE SHERIFFS OFFICE: http://registry.faa.gov/N911TS 

NTSB Identification: WPR16FA067 

14 CFR Part 91: General Aviation
Accident occurred Wednesday, February 10, 2016 in Springville, CA
Aircraft: FLIGHT DESIGN GMBH CTLS, registration: N911TS
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On February 10, 2016, at 1617 Pacific standard time, a Flight Design CTLS airplane, N911TS, while flying at low altitude entered a hard left turn and descended into terrain 4 miles southwest of Springville, California. The airline transport pilot and single passenger were fatally injured, and the airplane was destroyed by a post-crash fire. The airplane was registered to, and operated by, the Tulare County Sheriff as a public aircraft under the provisions of 14 Code of Federal Regulations, Part 91. Visual meteorological conditions prevailed for the flight, which operated on a visual flight rules company flight plan. The flight originated from Visalia Municipal Airport, Visalia, California, approximately 1440 as a local flight.

Witnesses reported seeing the airplane circling a nearby area then depart to the southwest. The airplane made a left turn, the wings dipped left and right, then the airplane descended into the ground in a sideways wing down orientation. The engine was heard operating in a steady tone until ground impact. A post-crash fire ensured, destroying the airplane.

The Porterville Municipal Airport automated weather observation system-3 (AWOS-3), located 11 miles southwest of the accident site, at an elevation of 443 feet mean sea level, recorded at 1556, wind from 300 degrees at 8 knots, visibility 10 statute miles, sky clear, and altimeter setting of 30.18 inHg.

FAA Flight Standards District Office: FAA Fresno FSDO-17

Pilot James Chavez and Tulare County sheriff's Deputy Scott Ballantyne.


Josiah James Chavez looks at the casket holding his father, Pilot James Chavez, at Grangeville Cemetery in Armona.


















Quad City International Airport (KMLI) seeing impact of pilot shortage



A nationwide pilot shortage is leaving its mark on the Quad-City International Airport, the airport's aviation director said Tuesday.

As Bruce Carter announced a 6 percent passenger decline for February, he said part of the decrease is due to the fact that with fewer pilots, the industry is switching to larger planes and fewer flights.

The airlines are "getting rid of the 50-seat regional jets and replacing them with 70 seats (aircraft)," he told the Rock Island County Metropolitan Airport Authority. 

According to Carter, United and Delta have reduced their weekend flight schedules at the airport. Fewer flights, he said "saves a crew from having to fly.

The switch has not had much of an impact on the total capacity available at the Moline airport. ''But the customer doesn't have as many choices," he said.

Cathie Rochau, the airport's marketing representative, said United and Delta have a combined total of 24 flights a day — departures and arrivals. But the weekend schedule ahead now has the total flights down to 17 on Saturdays and 21 on Sundays.

The airport's statistics show it had 25,910 passengers last month, down from 27,457 a year ago. The declines by carrier were Allegiant, down 6 percent; Delta Airlines, down 12 percent; and United Express, down 5 percent. American Eagle/Envoy's passenger enplanements saw no change.

Total passengers, enplanements and deplanements combined, were 50,275 in February. That was a 5 percent decline from 53,125 total passengers a year earlier. Year to date, total passengers are down 6 percent to 102,875 from 109,285 at this point last year.

Carter said part of the pilot shortage issue is the changing qualifications for pilots, including increased hours of flying to get licensed and FAA-mandated retirement age of 65.

According to an Aviation Week report, the regional carriers are losing pilots as they move up to the major airlines and fill their large ranks of retirements. In addition, the low beginning salaries at the regionals are failing to fill up the new pilot training classes.

"Some airports are losing all their air service if they can't support 70 seats," Carter said. "We're able to support 70 seat aircraft." 

Looking ahead, Carter said March is shaping up to be a strong month, in part, due to spring break travelers.

He and Rochau conducted a parking lot study Monday and counted 1,600 cars. Of those, he said 74 percent were from Iowa, which was up from 69 percent last year. "We saw big increases from Johnson and Linn counties," he added.

Original article can be found here:  http://qctimes.com

Aerodynamic Stall / Spin: Piper PA-46-310P Malibu, N4BP; accident occurred July 22, 2015 at Wittman Regional Airport (KOSH), Oshkosh, Wisconsin

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Milwaukee, Wisconsin 
Continental Motors; Mobile, Alabama 
Piper Aircraft; Vero Beach, Florida

Aviation Accident Final Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board:  https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N4BP

Location: Oshkosh, WI
Accident Number: CEN15FA311
Date & Time: 07/22/2015, 0744 CDT
Registration:N4BP 
Aircraft: PIPER PA-46-310P
Aircraft Damage: Substantial
Defining Event: Aerodynamic stall/spin
Injuries: 3 Serious, 2 Minor
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis

The pilot was landing at a large fly-in/airshow and following the airshow arrival procedures that were in use. While descending on the downwind leg for runway 27, the pilot was cleared by a controller to turn right onto the base leg abeam the runway numbers and to land on the green dot (located about 2,500 ft from the runway's displaced threshold). About the time the pilot turned onto the base leg, he observed an airplane taxi onto the runway and start its takeoff roll. The controller instructed the pilot to continue the approach and land on the orange dot (located about 1,000 ft from the runway's displaced threshold) instead of the green dot. The pilot reported that he considered performing a go-around but decided to continue the approach. As the pilot reduced power, the airplane entered a stall and impacted the runway in a right-wing-low, nose-down attitude. Witnesses estimated that the bank angle before impact was greater than 60 degrees. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Analysis of a video recording of the accident showed that the airplane was about 180 ft above ground level (agl) when the turn onto the base leg began, and it descended to about 140 ft agl during the turn. The airplane's total inertial speed (the calculated vector sums of the airplane's ground speeds and vertical speeds) decreased from 98 knots (kts) to 80 kts during the turn.  During the last 8 seconds of flight, the speed decreased below 70 kts, and the airplane descended from about 130 ft agl to ground impact. The wings-level stall speed of the airplane at maximum gross weight with landing gear and flaps down was 59 kts. In the same configuration at 60 degrees of bank, the stall speed was 86 kts and would have been higher at a bank angle greater than 60 degrees.

Reduced runway separation standards for airplanes were in effect due to the airshow. When the accident airplane reached the runway threshold, the minimum distance required by the standards between the arriving accident airplane and the departing airplane was 1,500 ft. The video analysis indicated that it was likely that a minimum of 1,500 ft of separation was maintained during the accident sequence.

Although the pilot was familiar with the procedures for flying into the airshow, the departing airplane and the modified landing clearance during a period of typically high workload likely interfered with the pilot's ability to adequately monitor his airspeed and altitude. As a result, the airplane entered an accelerated stall when the pilot turned the airplane at a steep bank angle and a low airspeed in an attempt to make the landing spot, which resulted in the airplane exceeding its critical angle of attack. At such a low altitude, recovery from the stall was not possible. Although the airshow arrival procedures stated that pilots have the option to go around if necessary, and the pilot considered going around, he instead continued the unstable landing approach and lost control of the airplane. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to perform a go-around after receiving a modified landing clearance and his failure to maintain adequate airspeed while maneuvering to land, which resulted in the airplane exceeding its critical angle of attack in a steep bank and entering an accelerated stall at a low altitude.

Findings

Aircraft
Airspeed - Not attained/maintained (Cause)
Lateral/bank control - Not attained/maintained (Cause)

Personnel issues
Aircraft control - Pilot (Cause)
Lack of action - Pilot (Cause)

Environmental issues
Traffic pattern procedure - Effect on operation

Factual Information

HISTORY OF FLIGHT


On July 22, 2015, about 0744 central daylight time, a Piper Malibu PA-46-310P single-engine airplane, N4BP, sustained substantial damage when it impacted runway 27 (6,179 ft by 150 ft, concrete) while landing at the Wittman Regional Airport (OSH), Oshkosh, Wisconsin. The pilot and two passengers sustained serious injuries and two passengers sustained minor injuries. The airplane was registered to DLM Holding Group LLC and operated by the pilot under the provisions of the 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The flight departed the Southwest Michigan Regional Airport (BEH), Benton Harbor, Michigan, about 0730 eastern daylight time. 

The pilot reported that he departed BEH and overflew Kenosha, Burlington, Hartford, Ripon, and Fisk, Wisconsin. He then proceeded to fly the Fisk arrival procedures for runway 27 which were in use per the notice to airmen (NOTAM) for the EAA AirVenture 2015 air show at OSH. The pilot reported that he entered the right downwind leg for runway 27 at 1,800 ft and started to descend while maintaining 90 kts airspeed. He reported that he was instructed by air traffic control (ATC) to turn onto the base leg abeam the runway numbers and to land on the green dot (located about 2,500 ft from the runway 27 displaced threshold). After he started the base turn, he observed a twin-engine airplane taxi onto runway 27 and start its takeoff roll. (A passenger in the Malibu identified the airplane on the runway as a Cessna "high-wing 4-seater") The pilot was concerned about the airplane on the runway and was worried about a collision. The pilot reported that ATC instructed him to continue the approach and land on the orange dot (located about 1,000 ft from the runway 27 displaced threshold) instead of the green dot. The pilot considered doing a go-around, but decided to continue the approach. He reported that about 250 to 300 ft above ground level, he pulled back on the power which resulted in the airplane entering a stall. He attempted to recover by adding full power, but the airplane impacted the runway in a right wing low, nose down attitude. The right wing hit the runway which resulted in an explosion with fire and black smoke rising above the accident site. The right wing separated from the airplane and landed in the grass on the south side of the runway. The airplane skidded on its belly and came to rest on the left side of the runway about 278 ft from the initial impact point. The left wing was partially separated from the fuselage and there was a fire under the left wing.

The two passengers who were sitting in the middle, rear-facing seats, and the passenger sitting in the rear seat exited the airplane with assistance from the pilot and people who arrived at the site soon after the accident. The Crash Fire Rescue (CFR) personnel arrived at the scene and used foam to put out the fire. The passenger sitting in the copilot's seat was extracted from the wreckage by the CFR. All five survivors were taken to local hospitals for treatment. 

Numerous witnesses reported that they saw the airplane on the base leg as it entered a steep right bank and impact the terrain in a steep nose down, right wing low attitude. One witness reported that he was located on the terminal ramp to the north of the approach end of runway 27. He heard an aircraft approaching from over the terminal building and observed that the airplane was very low – less than 200 ft above ground level (agl). The witness said that there was no indication that the airplane was in distress, such as a sputtering engine. He further reported that the airplane entered a steep right turn, with an estimated angle of bank of over 60 degrees and then impacted on its side with the right wing contacting the ground first. 

AIR TRAFFIC CONTROL COMMUNICATIONS

Special procedures and staffing for ATC were in effect during the Experimental Aircraft Association's AirVenture event. The North Local Control (NLC) team was located in the control tower. The team consisted of five controllers: two spotters, one communicator, a team leader, and a front-line manager (FLM) overseeing the operation. At the time of the accident, the NLC team was responsible for issuing landing clearances on runway 27. The Itinerant Mobile (IM) team, who had overall responsibility for ATC departure operations on runway 27, was working from a Mobile Operations Communications Workstation (MOOCOW) located at the intersection of runway 27 and taxiway A. The IM team was responsible for clearing aircraft for takeoff on runway 27 and consisted of four controllers: an aircraft communicator (AC), one spotter/coordinator, and two "crossers" who work directly with aircraft holding for departure on the taxiway. Communication between the IM and NLC teams was conducted via portable FM (frequency modulation) radios used by the MOOCOW AC and the NLC FLM, although coordination was kept to a minimum. The IM team was responsible for ensuring separation between arrivals and departures by monitoring the inbound pattern traffic and releasing departures when there was sufficient time to do so before the next aircraft landed.

Instructions for the Fisk arrival contained in the AirVenture NOTAM direct pilots to minimize radio transmissions and not respond to ATC communications. Review of recorded transmissions from the NLC team and the IM team showed that at 0742:24, the NLC communicator instructed a Malibu on downwind for runway 27 to begin descent. At 0742:44, the Malibu pilot was told to, "…turn abeam the numbers, runway 27 green dot cleared to land."

Before and during the period the Malibu was operating in the traffic pattern, the IM team was clearing departures for takeoff from runway 27. Between 0730 and 0743 there were about 22 departures. The last departure before the accident was "Cessna 44Q", cleared for takeoff at 0743:03. The IM communicator then continued, "44Q roll it around the corner – scoot!"

At 0743:11, the NLC communicator transmitted, "Malibu I've got somebody on the runway – keep it coming around keep it coming around cleared to land runway 27 orange dot, land as soon as you can."

At 0743:23, the IM communicator transmitted, "Don't turn your back – don't turn your back!"

There were no further transmissions on the IM frequency.

The tower controllers notified airport firefighters to respond, extinguish the post-crash fire, and assist the aircraft's occupants.

The IM communicator reported that the Malibu looked "normal" on downwind over the gravel pit, but the next time he saw it, the aircraft looked unusually low for a runway 27 arrival. The Malibu was west of the terminal building and had not yet started to turn right base. The next departure was holding short between 125 and 250 feet from the runway. Traffic was very light, and there were no other aircraft waiting to depart. The communicator cleared the Cessna for takeoff. The communicator then observed that the Malibu was lower and "tighter" on base than he expected, so he went on frequency and told the Cessna pilot to hurry up. The Cessna pilot never stopped, and made a rolling takeoff as requested. The Malibu was over the terminal building and then turning toward the runway. The communicator reported that by then, the departing Cessna was rolling and approaching or beyond the green dot on the runway. 

The communicator reported that the Malibu was on downwind west of the terminal building, and had not turned base yet when the Cessna was cleared for takeoff. He stated that controllers try to use minimum spacing during AirVenture, and to expedite traffic to avoid go-arounds. Because arriving aircraft were on the NLC frequency, the IM communicator could not directly instruct a pilot to go around. Should a go-around appear necessary, the IM team would contact the tower FLM via FM radio and the FLM would either override the tower frequency and send the aircraft around or ask the tower communicator to do so. The communicator stated that he had no reluctance to call for a go-around if he perceived an unsafe situation.

The communicator reported that while the Malibu was turning from downwind to base, it looked like it was making a continuous turn to final. Partway down the curving "base" leg, it briefly rolled wings level and was heading straight southbound. The Malibu was "very low" at that point. The communicator reported that the airplane overshot the final approach course and rolled into a very steep bank to try to line up with the runway. The wings looked almost perpendicular to the ground. He made the "don't turn your back" radio transmission, which was directed at one of the spotters, because the Malibu was in an unusual maneuver and the spotter needed to watch out for it. 

Runway Separation

Under normal circumstances, controllers would be required to maintain at least 3,000 ft of separation between a departing Cessna and an arriving Malibu using the same runway. According to the reduced runway separation standards authorized during AirVenture, the minimum required distance between the arriving Malibu and the departing Cessna was 1,500 ft when the Malibu reached the runway threshold. 

PERSONNEL INFORMATION

The 46-year-old pilot held a private pilot certificate with a single-engine land rating and an airplane instrument rating. He reported that he had 934 total hours of flight time with 130 hours in make and model. He held a third class medical certificate that was issued on December 3, 2014, with no limitations.

The pilot reported that he had flown to OSH during the EAA AirVenture Airshow numerous times and was familiar with the procedures for flying to OSH during the week of the airshow. He reported that on the morning of the accident, the airplane traffic was light and there was no other airplane on downwind when he was landing. He reported that he was surprised that the controllers cleared the "twin-engine" to taxi onto the runway and depart when he had already turned onto the base leg of the approach. He reported that he initially thought about doing a go-around, but decided to land when he was instructed to land on the orange dot. 

AIRCRAFT INFORMATION

The airplane was a single-engine Piper Malibu PA-46-310P, serial number 46-8408065, manufactured in 1984. It had a maximum gross weight of 4,100 lbs and it seated six. It was equipped with a Continental 300-horsepower TSIO 550-C (1) engine, serial number 802599. The last annual maintenance inspection was conducted on November 12, 2014, with a total airframe time of 5,792 hours. The engine had 1,439 hours since the last overhaul. 

METEOROLOGICAL INFORMATION

At 0740, the surface weather observation at OSH was: wind 250 degrees at 3 kts; visibility 10 miles; sky clear; temperature 19 degrees C; dew point 14 degrees C; altimeter 29.97 inches of mercury. 

WRECKAGE AND IMPACT INFORMATION

The airplane's initial impact point was just right of centerline in the threshold area of runway, 55 ft from the start of runway 27. The scraping on the runway and the burn path that was on a 238-degree heading led to the right wing which was190 ft from the initial contact point. Five parallel slash marks were found in the runway's concrete surface, which were consistent with propeller strikes. Three composite propeller blades were found in the debris field. All three blades were separated at the blade root and all exhibited extensive impact damage. 

The right wing was separated from the fuselage at the wing root. The wing was intact but it exhibited fire and impact damage, and the outboard span of the wing was bent upward and twisted. The right landing gear was found in the down position. The flap bellcrank was broken at the outboard rod end. The flap actuator was inspected and it indicated that the flaps were in the down position. The aileron remained attached to the wing. Both aileron cables were separated at the wing root.

The fuselage was located 278 ft from the initial impact point on a 242-degree heading. The left wing was still attached to the fuselage, but it was partially separated at the wing root. The flap and aileron remained attached to the left wing. The flap bellcrank was broken at the outboard rod end. Both aileron cables were separated at the wing root. The empennage remained attached to the fuselage and exhibited little impact damage. The elevator, rudder, and trim cables were connected to their control surfaces to the flight controls and control surface movement was confirmed. The hour meter indicated 1,452 hours. The JPI EDM-930 engine monitor was sent to the National Transportation Safety Board's (NTSB) Vehicle Recorder Laboratory for examination. 

The engine examination revealed that all the cylinders remained in place and attached to the crankcase. Cylinders Nos. 3 and 5 were impact damaged. The engine was manually rotated and there was thumb compression on all six cylinders, although the compression on Nos. 3 and 5 was weak due to the impact damage. Drive train continuity was confirmed when the engine was rotated and the accessory gears on the rear of the engine turned respectively. The top spark plugs were inspected and exhibited normal wear and color. The left and right magnetos produced spark and the impulse couplings were heard to operate when rotated. The fuel system remained intact. The fuel throttle body and metering unit were intact and undamaged. The fuel manifold diaphragm was intact and the fuel screen was uncontaminated. Aviation fuel was found in the fuel lines leading from the fuel manifold to the individual fuel injectors. The propeller hub remained attached to the crankshaft propeller flange. 

TESTS AND RESEARCH

JPI EDM-930 Engine Monitor

The NTSB Vehicle Recorder Laboratory examined the JPI EDM-930 engine monitor's non-volatile memory (NVM) and it was determined that the accident flight was recorded. The recorded time was correlated to central daylight time. 

The recording began around 06:20. Values for exhaust gas temperature and cylinder head temperature began to rise. Around 06:30, manifold pressure and engine RPM rapidly increased consistent with the aircraft beginning a takeoff roll. Most recorded parameters remained stable from approximately 06:35 until approximately 07:25. 

At 07:25, manifold pressure was reduced. Fuel flow, oil pressure, oil temperature, EGT and CHT all began slightly negative trends. Near the end of the recording, around 07:43, manifold pressure sharply decreased in value along with engine RPM. In the last recorded values, engine RPM, manifold pressure, fuel flow and values for CHT and EGT began to sharply rise. The recording ended abruptly at 07:44.The engine parameters were generally increasing in value just prior to the recording abruptly ending at 07:44. The NTSB Engine Data Monitor (EDM) report has been entered in the docket. 

NTSB Video Study

The NTSB Office of Research and Engineering produced a video study based on a video recording of the accident flight. The Malibu was captured in a video for approximately eighteen seconds before it impacted the ground on runway 27. The video was recorded by a Kodak SP360 camera mounted inside the cockpit of a parked airplane that was not involved in the accident. The camera had a 360-degree panoramic field of view. The location of the parked airplane was on the north ramp near the airport terminal. 

The video study estimated that the altitude of the Malibu as it initiated its turn to base leg was about 180 ft agl, and it descended to about 150 to 130 feet agl on the base leg. During the last 8 seconds of flight, the Malibu descended from about 130 ft agl to ground impact. The total inertial speed (the vector sums of the ground speeds and vertical speeds) was calculated and it showed that the Malibu was traveling at 98 kts decreasing to 80 kts during the turn to the base leg. The speed continued to decrease and during the last 8 seconds of flight, the speed was below 70 kts. 

The video study also analyzed the location of the second airplane (Cessna) that taxied onto runway 27 and departed as the Malibu turned onto the base leg. The video was analyzed to determine how much distance was between the two airplanes during the accident sequence. At time 5:06 in the video, an object is seen moving east to west and is assumed to be the departing Cessna on runway 27. It is only seen for a fraction of a second because the camera view was obstructed. Because the Cessna was on the ground and far from the camera, its image in the video is only a barely visible moving dot. The straight line distance between the Cessna, when it was seen on the video, and the Malibu, which was on its base leg, was about 1,570 ft. The analysis indicated that to keep a 1,500 ft distance between the two airplanes, if the Malibu had completed its turn to final which would take 9.4 seconds, the Cessna would have to move to the west at an average speed of 45.7 kts. 

ADDITIONAL INFORMATION

Angle of Bank vs Airspeed

The Piper Malibu PA-46-310P Pilot's Operating Handbook (POH) figure 5-3 lists stall speeds corrected for aircraft bank angle. The stall speed for a Piper PA-46-310P at 4,100 lbs with gear and flaps down at 0 degrees angle of bank is 59 kts. With the same configuration, it shows the stall speed is 86 kts at 60 degrees of bank, and would have been higher at an angle of bank greater than 60 degrees. 

The "Airplane Flying Handbook FAA-H-8083-3A" provided the following information about accelerated stalls: 

"Though the stalls just discussed normally occur at a specific airspeed, the pilot must thoroughly understand that all stalls result solely from attempts to fly at excessively high angles of attack. During flight, the angle of attack of an airplane wing is determined by a number of factors, the most important of which are airspeed, the gross weight of the airplane, and the load factors imposed by maneuvering." 

"At the same gross weight, airplane configuration, and power setting, a given airplane will consistently stall at the same indicated airspeed if no acceleration is involved. The airplane will, however, stall at a higher indicated airspeed when excessive maneuvering loads are imposed by steep turns, pull-ups, or other abrupt changes in the flight path. Stalls entered from such flight situations are called 'accelerated maneuver stalls,' a term, which has no reference to the airspeeds involved." 

EAA AirVenture 2015 NOTAM

The EAA AirVenture 2015 NOTAM stated the following concerning landing approach at Oshkosh:

"A waiver has been issued reducing arrival and departure separation standards for category 1 and 2 aircraft (primarily single-engine and light twin-engine aircraft). 

Pilots should be prepared for a combination of maneuvers that may include a short approach with descending turns, followed by a touchdown at a point specified by ATC which may be almost halfway down the runway. Use extra caution to maintain a safe airspeed throughout the approach to landing." 

The NOTAM stated: "If a go-around is needed, notify ATC immediately for resequencing instructions." It also stated, "Maintain a safe airspeed and avoid low turns on landing approach." 





NTSB Identification: CEN15FA311
14 CFR Part 91: General Aviation
Accident occurred Wednesday, July 22, 2015 in Oshkosh, WI
Aircraft: PIPER PA-46-310P, registration: N4BP
Injuries: 3 Serious, 2 Minor.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On July 22, 2015, about 0744 central daylight time, a Piper PA-46-310P single-engine airplane, N4BP, sustained substantial damage when it impacted runway 27 (6,179 ft by 150 ft, concrete) while landing at the Wittman Regional Airport (OSH), Oshkosh, Wisconsin. The pilot and two passengers sustained serious injuries and two passengers sustained minor injuries. The airplane was registered to DLM Holding Group LLC and operated by the pilot under the provisions of the 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The flight departed the Southwest Michigan Regional Airport (BEH), Benton Harbor, Michigan, about 0730 eastern daylight time. 

The pilot reported that he departed BEH and overflew Kenosha, Burlington, Hartford, Ripon, and Fisk, Wisconsin. He then proceeded to fly the Fisk arrival procedures for runway 27 which were in use per the notice to airmen (NOTAM) for the EAA AirVenture 2015 air show at OSH. The pilot reported that he entered the right downwind leg for runway 27 at 1,800 ft and started to descend while maintaining 90 kts airspeed. He reported that he was instructed by air traffic control (ATC) to turn onto the base leg abeam the runway numbers and to land on the green dot (located about 2,500 ft from the runway 27 displaced threshold). After he started the base turn, he observed a twin-engine airplane taxi onto runway 27 and start its takeoff roll. The pilot reported that ATC instructed him to continue the approach and land on the orange dot (located about 1,000 ft from the runway 27 displaced threshold) instead of the green dot. The pilot continued the approach and about 250 to 300 ft above ground level, he pulled back on the power which resulted in the airplane entering a stall. The pilot attempted to recover by adding full power, but the airplane impacted the runway in a right wing, nose down attitude. 

Witnesses reported seeing the airplane during the downwind to base turn and enter a steep angle of bank with the right wing down. The right wing hit the runway which resulted in an explosion and fire with black smoke rising above the accident site. The right wing separated from the airplane and landed in the grass on the south side of the runway. The airplane skidded on its belly and came to rest on the left side of the runway about 250 ft from the initial impact point. The left wing was partially separated from the fuselage. A postimpact fire ensued on the separated right wing and under the partially separated left wing.

The pilot, the two passengers who were sitting in the middle seats, and the passenger sitting in the rear seat exited the airplane with some assistance from people who were near the accident site. The Crash Fire Rescue (CFR) personnel arrived at the scene and used foam to put out the fire. The passenger sitting in the copilot's seat was extracted from the wreckage by the CFR. All five survivors were taken to local hospitals for treatment. 

At 0740, the surface weather observation at OSH was: wind 250 degrees at 3 kts; visibility 10 miles; sky clear; temperature 19 degrees C; dew point 14 degrees C; altimeter 29.97 inches of mercury. The steep angle of the Piper PA-46, along with a low airspeed, caused the plane to stall after the pilot received a change in instructions on where to land, according to a probable cause report the National Transportation Safety Board released Thursday.

"Although the pilot was familiar with the procedures for flying into the airshow, the departing airplane and the modified landing clearance during a period of typically high workload likely interfered with the pilot's ability to adequately monitor his airspeed and altitude," according to the NTSB report.

The plane, piloted by Kenneth J. Kaminski, 46, of Benton Harbor, Michigan, crashed at 7:44 a.m. July 22 at Wittman Regional Airport, after control tower dispatchers originally instructed Kaminski to land at the east end of Runway 27, according to a preliminary NTSB report on the crash.

Upon descent, Kaminski saw a twin-engine airplane taxi onto Runway 27 and start taking off, according to the report. Air traffic control dispatchers told him to continue his approach and land at a different spot, further down the runway. About 250 feet to 300 feet above the ground, the pilot decreased power, causing the plane to stall and subsequently crash.



NTSB Identification: CEN15FA311
14 CFR Part 91: General Aviation
Accident occurred Wednesday, July 22, 2015 in Oshkosh, WI
Probable Cause Approval Date: 03/09/2016
Aircraft: PIPER PA-46-310P, registration: N4BP
Injuries: 3 Serious, 2 Minor.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The pilot was landing at a large fly-in/airshow and following the airshow arrival procedures that were in use. While descending on the downwind leg for runway 27, the pilot was cleared by a controller to turn right onto the base leg abeam the runway numbers and to land on the green dot (located about 2,500 ft from the runway's displaced threshold). About the time the pilot turned onto the base leg, he observed an airplane taxi onto the runway and start its takeoff roll. The controller instructed the pilot to continue the approach and land on the orange dot (located about 1,000 ft from the runway's displaced threshold) instead of the green dot. The pilot reported that he considered performing a go-around but decided to continue the approach. As the pilot reduced power, the airplane entered a stall and impacted the runway in a right-wing-low, nose-down attitude. Witnesses estimated that the bank angle before impact was greater than 60 degrees. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Analysis of a video recording of the accident showed that the airplane was about 180 ft above ground level (agl) when the turn onto the base leg began, and it descended to about 140 ft agl during the turn. The airplane's total inertial speed (the calculated vector sums of the airplane's ground speeds and vertical speeds) decreased from 98 knots (kts) to 80 kts during the turn. During the last 8 seconds of flight, the speed decreased below 70 kts, and the airplane descended from about 130 ft agl to ground impact. The wings-level stall speed of the airplane at maximum gross weight with landing gear and flaps down was 59 kts. In the same configuration at 60 degrees of bank, the stall speed was 86 kts and would have been higher at a bank angle greater than 60 degrees. 

Reduced runway separation standards for airplanes were in effect due to the airshow. When the accident airplane reached the runway threshold, the minimum distance required by the standards between the arriving accident airplane and the departing airplane was 1,500 ft. The video analysis indicated that it was likely that a minimum of 1,500 ft of separation was maintained during the accident sequence.

Although the pilot was familiar with the procedures for flying into the airshow, the departing airplane and the modified landing clearance during a period of typically high workload likely interfered with the pilot's ability to adequately monitor his airspeed and altitude. As a result, the airplane entered an accelerated stall when the pilot turned the airplane at a steep bank angle and a low airspeed in an attempt to make the landing spot, which resulted in the airplane exceeding its critical angle of attack. At such a low altitude, recovery from the stall was not possible. Although the airshow arrival procedures stated that pilots have the option to go around if necessary, and the pilot considered going around, he instead continued the unstable landing approach and lost control of the airplane.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to perform a go-around after receiving a modified landing clearance and his failure to maintain adequate airspeed while maneuvering to land, which resulted in the airplane exceeding its critical angle of attack in a steep bank and entering an accelerated stall at a low altitude. 




HISTORY OF FLIGHT

On July 22, 2015, about 0744 central daylight time, a Piper Malibu PA-46-310P single-engine airplane, N4BP, sustained substantial damage when it impacted runway 27 (6,179 ft by 150 ft, concrete) while landing at the Wittman Regional Airport (OSH), Oshkosh, Wisconsin. The pilot and two passengers sustained serious injuries and two passengers sustained minor injuries. The airplane was registered to DLM Holding Group LLC and operated by the pilot under the provisions of the 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The flight departed the Southwest Michigan Regional Airport (BEH), Benton Harbor, Michigan, about 0730 eastern daylight time. 

The pilot reported that he departed BEH and overflew Kenosha, Burlington, Hartford, Ripon, and Fisk, Wisconsin. He then proceeded to fly the Fisk arrival procedures for runway 27 which were in use per the notice to airmen (NOTAM) for the EAA AirVenture 2015 air show at OSH. The pilot reported that he entered the right downwind leg for runway 27 at 1,800 ft and started to descend while maintaining 90 kts airspeed. He reported that he was instructed by air traffic control (ATC) to turn onto the base leg abeam the runway numbers and to land on the green dot (located about 2,500 ft from the runway 27 displaced threshold). After he started the base turn, he observed a twin-engine airplane taxi onto runway 27 and start its takeoff roll. (A passenger in the Malibu identified the airplane on the runway as a Cessna "high-wing 4-seater") The pilot was concerned about the airplane on the runway and was worried about a collision. The pilot reported that ATC instructed him to continue the approach and land on the orange dot (located about 1,000 ft from the runway 27 displaced threshold) instead of the green dot. The pilot considered doing a go-around, but decided to continue the approach. He reported that about 250 to 300 ft above ground level, he pulled back on the power which resulted in the airplane entering a stall. He attempted to recover by adding full power, but the airplane impacted the runway in a right wing low, nose down attitude. The right wing hit the runway which resulted in an explosion with fire and black smoke rising above the accident site. The right wing separated from the airplane and landed in the grass on the south side of the runway. The airplane skidded on its belly and came to rest on the left side of the runway about 278 ft from the initial impact point. The left wing was partially separated from the fuselage and there was a fire under the left wing.

The two passengers who were sitting in the middle, rear-facing seats, and the passenger sitting in the rear seat exited the airplane with assistance from the pilot and people who arrived at the site soon after the accident. The Crash Fire Rescue (CFR) personnel arrived at the scene and used foam to put out the fire. The passenger sitting in the copilot's seat was extracted from the wreckage by the CFR. All five survivors were taken to local hospitals for treatment. 

Numerous witnesses reported that they saw the airplane on the base leg as it entered a steep right bank and impact the terrain in a steep nose down, right wing low attitude. One witness reported that he was located on the terminal ramp to the north of the approach end of runway 27. He heard an aircraft approaching from over the terminal building and observed that the airplane was very low – less than 200 ft above ground level (agl). The witness said that there was no indication that the airplane was in distress, such as a sputtering engine. He further reported that the airplane entered a steep right turn, with an estimated angle of bank of over 60 degrees and then impacted on its side with the right wing contacting the ground first. 




AIR TRAFFIC CONTROL COMMUNICATIONS

Special procedures and staffing for ATC were in effect during the Experimental Aircraft Association's AirVenture event. The North Local Control (NLC) team was located in the control tower. The team consisted of five controllers: two spotters, one communicator, a team leader, and a front-line manager (FLM) overseeing the operation. At the time of the accident, the NLC team was responsible for issuing landing clearances on runway 27. The Itinerant Mobile (IM) team, who had overall responsibility for ATC departure operations on runway 27, was working from a Mobile Operations Communications Workstation (MOOCOW) located at the intersection of runway 27 and taxiway A. The IM team was responsible for clearing aircraft for takeoff on runway 27 and consisted of four controllers: an aircraft communicator (AC), one spotter/coordinator, and two "crossers" who work directly with aircraft holding for departure on the taxiway. Communication between the IM and NLC teams was conducted via portable FM (frequency modulation) radios used by the MOOCOW AC and the NLC FLM, although coordination was kept to a minimum. The IM team was responsible for ensuring separation between arrivals and departures by monitoring the inbound pattern traffic and releasing departures when there was sufficient time to do so before the next aircraft landed.

Instructions for the Fisk arrival contained in the AirVenture NOTAM direct pilots to minimize radio transmissions and not respond to ATC communications. Review of recorded transmissions from the NLC team and the IM team showed that at 0742:24, the NLC communicator instructed a Malibu on downwind for runway 27 to begin descent. At 0742:44, the Malibu pilot was told to, "…turn abeam the numbers, runway 27 green dot cleared to land."

Before and during the period the Malibu was operating in the traffic pattern, the IM team was clearing departures for takeoff from runway 27. Between 0730 and 0743 there were about 22 departures. The last departure before the accident was "Cessna 44Q", cleared for takeoff at 0743:03. The IM communicator then continued, "44Q roll it around the corner – scoot!"

At 0743:11, the NLC communicator transmitted, "Malibu I've got somebody on the runway – keep it coming around keep it coming around cleared to land runway 27 orange dot, land as soon as you can."

At 0743:23, the IM communicator transmitted, "Don't turn your back – don't turn your back!"

There were no further transmissions on the IM frequency.

The tower controllers notified airport firefighters to respond, extinguish the post-crash fire, and assist the aircraft's occupants.

The IM communicator reported that the Malibu looked "normal" on downwind over the gravel pit, but the next time he saw it, the aircraft looked unusually low for a runway 27 arrival. The Malibu was west of the terminal building and had not yet started to turn right base. The next departure was holding short between 125 and 250 feet from the runway. Traffic was very light, and there were no other aircraft waiting to depart. The communicator cleared the Cessna for takeoff. The communicator then observed that the Malibu was lower and "tighter" on base than he expected, so he went on frequency and told the Cessna pilot to hurry up. The Cessna pilot never stopped, and made a rolling takeoff as requested. The Malibu was over the terminal building and then turning toward the runway. The communicator reported that by then, the departing Cessna was rolling and approaching or beyond the green dot on the runway. 

The communicator reported that the Malibu was on downwind west of the terminal building, and had not turned base yet when the Cessna was cleared for takeoff. He stated that controllers try to use minimum spacing during AirVenture, and to expedite traffic to avoid go-arounds. Because arriving aircraft were on the NLC frequency, the IM communicator could not directly instruct a pilot to go around. Should a go-around appear necessary, the IM team would contact the tower FLM via FM radio and the FLM would either override the tower frequency and send the aircraft around or ask the tower communicator to do so. The communicator stated that he had no reluctance to call for a go-around if he perceived an unsafe situation.

The communicator reported that while the Malibu was turning from downwind to base, it looked like it was making a continuous turn to final. Partway down the curving "base" leg, it briefly rolled wings level and was heading straight southbound. The Malibu was "very low" at that point. The communicator reported that the airplane overshot the final approach course and rolled into a very steep bank to try to line up with the runway. The wings looked almost perpendicular to the ground. He made the "don't turn your back" radio transmission, which was directed at one of the spotters, because the Malibu was in an unusual maneuver and the spotter needed to watch out for it. 



Runway Separation

Under normal circumstances, controllers would be required to maintain at least 3,000 ft of separation between a departing Cessna and an arriving Malibu using the same runway. According to the reduced runway separation standards authorized during AirVenture, the minimum required distance between the arriving Malibu and the departing Cessna was 1,500 ft when the Malibu reached the runway threshold. 

PERSONNEL INFORMATION

The 46-year-old pilot held a private pilot certificate with a single-engine land rating and an airplane instrument rating. He reported that he had 934 total hours of flight time with 130 hours in make and model. He held a third class medical certificate that was issued on December 3, 2014, with no limitations.

The pilot reported that he had flown to OSH during the EAA AirVenture Airshow numerous times and was familiar with the procedures for flying to OSH during the week of the airshow. He reported that on the morning of the accident, the airplane traffic was light and there was no other airplane on downwind when he was landing. He reported that he was surprised that the controllers cleared the "twin-engine" to taxi onto the runway and depart when he had already turned onto the base leg of the approach. He reported that he initially thought about doing a go-around, but decided to land when he was instructed to land on the orange dot. 




AIRCRAFT INFORMATION

The airplane was a single-engine Piper Malibu PA-46-310P, serial number 46-8408065, manufactured in 1984. It had a maximum gross weight of 4,100 lbs and it seated six. It was equipped with a Continental 300-horsepower TSIO 550-C (1) engine, serial number 802599. The last annual maintenance inspection was conducted on November 12, 2014, with a total airframe time of 5,792 hours. The engine had 1,439 hours since the last overhaul. 

METEOROLOGICAL INFORMATION

At 0740, the surface weather observation at OSH was: wind 250 degrees at 3 kts; visibility 10 miles; sky clear; temperature 19 degrees C; dew point 14 degrees C; altimeter 29.97 inches of mercury. 

WRECKAGE AND IMPACT INFORMATION

The airplane's initial impact point was just right of centerline in the threshold area of runway, 55 ft from the start of runway 27. The scraping on the runway and the burn path that was on a 238-degree heading led to the right wing which was190 ft from the initial contact point. Five parallel slash marks were found in the runway's concrete surface, which were consistent with propeller strikes. Three composite propeller blades were found in the debris field. All three blades were separated at the blade root and all exhibited extensive impact damage. 

The right wing was separated from the fuselage at the wing root. The wing was intact but it exhibited fire and impact damage, and the outboard span of the wing was bent upward and twisted. The right landing gear was found in the down position. The flap bellcrank was broken at the outboard rod end. The flap actuator was inspected and it indicated that the flaps were in the down position. The aileron remained attached to the wing. Both aileron cables were separated at the wing root.

The fuselage was located 278 ft from the initial impact point on a 242-degree heading. The left wing was still attached to the fuselage, but it was partially separated at the wing root. The flap and aileron remained attached to the left wing. The flap bellcrank was broken at the outboard rod end. Both aileron cables were separated at the wing root. The empennage remained attached to the fuselage and exhibited little impact damage. The elevator, rudder, and trim cables were connected to their control surfaces to the flight controls and control surface movement was confirmed. The hour meter indicated 1,452 hours. The JPI EDM-930 engine monitor was sent to the National Transportation Safety Board's (NTSB) Vehicle Recorder Laboratory for examination. 

The engine examination revealed that all the cylinders remained in place and attached to the crankcase. Cylinders Nos. 3 and 5 were impact damaged. The engine was manually rotated and there was thumb compression on all six cylinders, although the compression on Nos. 3 and 5 was weak due to the impact damage. Drive train continuity was confirmed when the engine was rotated and the accessory gears on the rear of the engine turned respectively. The top spark plugs were inspected and exhibited normal wear and color. The left and right magnetos produced spark and the impulse couplings were heard to operate when rotated. The fuel system remained intact. The fuel throttle body and metering unit were intact and undamaged. The fuel manifold diaphragm was intact and the fuel screen was uncontaminated. Aviation fuel was found in the fuel lines leading from the fuel manifold to the individual fuel injectors. The propeller hub remained attached to the crankshaft propeller flange. 

TESTS AND RESEARCH

JPI EDM-930 Engine Monitor

The NTSB Vehicle Recorder Laboratory examined the JPI EDM-930 engine monitor's non-volatile memory (NVM) and it was determined that the accident flight was recorded. The recorded time was correlated to central daylight time. 

The recording began around 06:20. Values for exhaust gas temperature and cylinder head temperature began to rise. Around 06:30, manifold pressure and engine RPM rapidly increased consistent with the aircraft beginning a takeoff roll. Most recorded parameters remained stable from approximately 06:35 until approximately 07:25. 

At 07:25, manifold pressure was reduced. Fuel flow, oil pressure, oil temperature, EGT and CHT all began slightly negative trends. Near the end of the recording, around 07:43, manifold pressure sharply decreased in value along with engine RPM. In the last recorded values, engine RPM, manifold pressure, fuel flow and values for CHT and EGT began to sharply rise. The recording ended abruptly at 07:44.The engine parameters were generally increasing in value just prior to the recording abruptly ending at 07:44. The NTSB Engine Data Monitor (EDM) report has been entered in the docket. 

NTSB Video Study

The NTSB Office of Research and Engineering produced a video study based on a video recording of the accident flight. The Malibu was captured in a video for approximately eighteen seconds before it impacted the ground on runway 27. The video was recorded by a Kodak SP360 camera mounted inside the cockpit of a parked airplane that was not involved in the accident. The camera had a 360-degree panoramic field of view. The location of the parked airplane was on the north ramp near the airport terminal. 

The video study estimated that the altitude of the Malibu as it initiated its turn to base leg was about 180 ft agl, and it descended to about 150 to 130 feet agl on the base leg. During the last 8 seconds of flight, the Malibu descended from about 130 ft agl to ground impact. The total inertial speed (the vector sums of the ground speeds and vertical speeds) was calculated and it showed that the Malibu was traveling at 98 kts decreasing to 80 kts during the turn to the base leg. The speed continued to decrease and during the last 8 seconds of flight, the speed was below 70 kts. 

The video study also analyzed the location of the second airplane (Cessna) that taxied onto runway 27 and departed as the Malibu turned onto the base leg. The video was analyzed to determine how much distance was between the two airplanes during the accident sequence. At time 5:06 in the video, an object is seen moving east to west and is assumed to be the departing Cessna on runway 27. It is only seen for a fraction of a second because the camera view was obstructed. Because the Cessna was on the ground and far from the camera, its image in the video is only a barely visible moving dot. The straight line distance between the Cessna, when it was seen on the video, and the Malibu, which was on its base leg, was about 1,570 ft. The analysis indicated that to keep a 1,500 ft distance between the two airplanes, if the Malibu had completed its turn to final which would take 9.4 seconds, the Cessna would have to move to the west at an average speed of 45.7 kts. 

ADDITIONAL INFORMATION

Angle of Bank vs Airspeed

The Piper Malibu PA-46-310P Pilot's Operating Handbook (POH) figure 5-3 lists stall speeds corrected for aircraft bank angle. The stall speed for a Piper PA-46-310P at 4,100 lbs with gear and flaps down at 0 degrees angle of bank is 59 kts. With the same configuration, it shows the stall speed is 86 kts at 60 degrees of bank, and would have been higher at an angle of bank greater than 60 degrees. 

The "Airplane Flying Handbook FAA-H-8083-3A" provided the following information about accelerated stalls: 

"Though the stalls just discussed normally occur at a specific airspeed, the pilot must thoroughly understand that all stalls result solely from attempts to fly at excessively high angles of attack. During flight, the angle of attack of an airplane wing is determined by a number of factors, the most important of which are airspeed, the gross weight of the airplane, and the load factors imposed by maneuvering." 

"At the same gross weight, airplane configuration, and power setting, a given airplane will consistently stall at the same indicated airspeed if no acceleration is involved. The airplane will, however, stall at a higher indicated airspeed when excessive maneuvering loads are imposed by steep turns, pull-ups, or other abrupt changes in the flight path. Stalls entered from such flight situations are called 'accelerated maneuver stalls,' a term, which has no reference to the airspeeds involved." 

EAA AirVenture 2015 NOTAM


The EAA AirVenture 2015 NOTAM stated the following concerning landing approach at Oshkosh:

"A waiver has been issued reducing arrival and departure separation standards for category 1 and 2 aircraft (primarily single-engine and light twin-engine aircraft). 

Pilots should be prepared for a combination of maneuvers that may include a short approach with descending turns, followed by a touchdown at a point specified by ATC which may be almost halfway down the runway. Use extra caution to maintain a safe airspeed throughout the approach to landing." 

The NOTAM stated: "If a go-around is needed, notify ATC immediately for resequencing instructions." It also stated, "Maintain a safe airspeed and avoid low turns on landing approach."